Question

Please explain why the following course objectives are important for medical billers and coder to understand:

Explain the components of physician medical billing

Identify the differences between inpatient and outpatient hospital billing and describe the UB-04 hospital claim form

Discuss Medicare fee schedules, provider reimbursement, fraud, and abuse

Explain Medicaid eligibility and benefits and the process of submitting Medicaid claims

Answer 1

The components of physician medical billing

Physician billing, also recognized as professional billing is the billing of claims for work that was due by a physician or other healthcare professionals, including inpatient and outpatient services. Most all of these claims are billed electronically as the 837-P form. The paper equivalent of this form is CMS-1500.

· Primary care physicians

· Specialty care physicians

· Radiologists

· Pathologists

· Anesthesiologists

· Surgeons

· Emergency room physicians

· Hospitalists

Differences between inpatient and outpatient hospital billing

One of the majority vital deliberations so as to describe the correct code option is whether the patient is an inpatient or outpatient.

Now the way to conclude the difference is

Inpatient: An inpatient is a person who has been publicly acknowledged to the hospital beneath a physician’s order. The patient leftovers a inpatient in anticipation of the day by the day of discharge.

Outpatient: A patient who approaches throughout the crisis room and is being treated or who is enduring tests but has not been confessed to the hospital is an outpatient, still if she expends the night.

Describe the UB-04 hospital claim form

The UB-04 uniform billing form is the typical declare form that any institutional provider can utilize for the billing of medical and mental health claims. It is printed with red ink on white regular paper. Even though urbanized by the Centers for Medicare and Medicaid (CMS), the form has become the customary form utilized by all insurance carriers.

Medicare fee schedules, provider reimbursement, fraud, and abuse

A fee schedule is a total listing of fees utilized by Medicare to disburse doctors or further providers/suppliers. This inclusive listing of fee maximums is utilized to pay back a physician and/or other providers on a fee-for-service source

Healthcare providers are remunerated by insurance or government payers throughout a system of repayment. After you collect a medical service, your provider sends a bill to whoever is accountable for casing your medical costs

Fraud is a deliberate deception or falsification of truth so as to result in not permitted benefit or payment

• submitting claims for services not offered or used
• misrepresentation claims or medical records
• misrepresenting dates, frequency, duration or description of services rendered

Abuse means events that are improper, inappropriate, outside acceptable standards of professional conduct or medically unnecessary.

Examples of Abuse

• a pattern of waiving cost-shares or deductibles
• malfunction to continue sufficient medical or financial records

Medicaid eligibility

To be suitable for Medicaid, individuals must also meet definite non-financial eligibility criteria.

Federal Employees Health Benefit Plan

State Employee Plan.

Health Maintenance Organization (HMO) Plan

A person may offer the Medicaid claims for processing or it can be completed for them by the medical provider. An individual typically submits the claims for repayment if the medical provider was not able to present the Medicaid claims for them.

After finishing the Medicaid claims processing form, it may be sent jointly with the resultant receipts and other essential documentation by mail to the address listed on the claim form. These may also be faxed to a number that is also found on the form. The state’s Medicaid claim processing group will then review the claims submitted by the individual and establish if it will be reimbursed or not. They will check if the information on the form is complete and correct. If they find any errors or there are missing information, they will send it back to the person who sent it with the reasons why they did not process the Medicaid claim.